Four Provider Strategies for Managing Post-Discharge Patients

Days after a stroke, a 59-year-old male is discharged from the hospital into a post-acute facility. The success of this patient transfer, and all other transfers, depends greatly on how well these healthcare providers coordinate and share information.

A January 2018 survey of 162 hospitals by HIMSS Media, however, uncovered numerous gaps between hospitals and post-acute providers that result in operational and clinical inefficiencies. Filling these gaps – thereby creating a smoother, more efficient and effective handoff between acute and post-acute care – results in lower costs, appropriate utilization and improved patient outcomes. That’s key, given the industry’s switch from volume- to value-based compensation, such as those under accountable care or bundled payment models, and as more and more care is delivered in post-acute settings.

“Hospitals are tied financially to these skilled nursing facilities, whether they want to be or not,” said Mary Kay Thalken, Chief Clinical Officer at Ensocare. “They’re responsible for the utilization and quality outcomes...They own that patient.”

Thalken highlighted four strategies that can help hospitals better manage post-acute patients.

Provider management: Use multiple processes

The survey revealed that only 26 percent of respondents are partnering with post-acute providers to track patient care and that more than half (53 percent) are either uncertain or have no real processes in place to manage post-acute providers. For those with processes, just 7 percent make use of automated discharge or referral management software.

“What’s remarkable is the large number that isn’t using any type of technology to bridge the communication gap,” Thalken said. The survey found some 25 percent of providers still communicate manually (phone calls, faxes and paper documents), and that manual processes are much more common among small-to-mid-size organizations, those with 500 or fewer beds or 1,000 or fewer employees. Inferior or absent technology puts post-acute providers in jeopardy, as hospitals begin insisting on quantified data about quality and patient outcomes.

To enable these data-driven discussions, Thalken said it’s important to have multiple processes in place – for example, internal analytics and performance data; automated discharge or referral management software; Medicare quality ratings; training of post-acute providers; and physicians inside post-acute facilities. However, multiple processes are uncommon. The survey found only a quarter of respondents have two or more of these processes in place to manage post-acute providers. Significantly, EHRs – far and away the top technology used to manage patient discharges and post-acute referrals, cited by 64 percent of respondents in the survey – “have no fields per se on post-acute outcomes,” Thalken said.

Patient monitoring: Use multiple practices

Getting patients to comply with care plans remains a top challenge. At 84 percent, it was the leading challenge cited by survey respondents, ahead of communication gaps between care providers (61 percent), medication management issues (56 percent) and patient access to social services (52 percent). But even this may point to an underlying technology breakdown in the post-acute care transition, Thalken said, noting that without robust and detailed information, patients and their families can’t fully participate in ongoing and proactive care management.

Indeed, while the survey found 8 out of 10 providers have practices to monitor patients post-discharge, the top approach, at 41 percent, was manual: nurse navigators who call and check on patients. Just 36 percent of respondents offer access to a secure cloud-based communications portal for patients, family and providers, and only 30 percent provide access to telemedicine services.

Harnessing automation to keep patient data and care plans synchronized between acute and post-acute providers improves both the healthcare organization and patient outcomes, Thalken added. “Incorporating enabling technology into this workflow gives case managers roughly 50 percent of their day back,” she said. That savings means more time spent with patients and their families, which means better understanding of patient needs and more precise care plans.

Leverage risk-assessment data and analytics

“New technology and improved data sharing will make quality outcomes more predictable,” Thalken said. Enabling technologies will include biometric remote monitoring of key health indicators and risk-assessment analytics, she added. Two-thirds of providers are using or have plans to use risk-assessment data or predictive analytics to determine which patients need greater post-discharge oversight, according to the survey.

Develop ‘preferred’ relationships with post-acute providers

Only 26 percent of survey respondents have created partnerships with “preferred” post-acute providers. Here again, the survey found a stark imbalance between large and mid-sized organizations on this score (34 percent of large organizations versus just 14 percent of small- to mid-sized organizations).

“There’s a great deal of potential here,” Thalken said. She noted more and more hospitals are spending time determining which of their post-acute care provider “superior performers” are leveraging technology to track and improve patient outcomes. “We’ve seen [the hospital, the referring physician, the post-acute facility] doing a quarterly debrief on all the readmissions, figuring out what they could have done differently and having fact-based conversations,” she said.

“Gone are the days when hospitals would wheel a patient to the door and bid them a fond farewell,” Thalken pointed out. “Now when we take them to the door, the hospital holds itself accountable for that patient’s care and wellbeing by calling them [post-discharge], scheduling appointments and transportation, and working closely with the post-acute providers to make sure everything is on track.”

Check out the Infographic for more eye-opening findings from the Ensocare and HIMSS Media survey!